Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report

Donald M. Yealy MD , Nicholas M. Mohr MD, MS , Nathan I. Shapiro MD , Arjun Venkatesh MD, MBA

Alan E. Jones MD  and Wesley H. Self MD, MPH

Annals of Emergency Medicine, Copyright © 2021 American College of Emergency Physicians

Introduction

Sepsis is a major cause of hospital death in the United States (US)  and is associated with over 850,000 annual emergency department visits.  Despite advances in care, patients with serious infection continue to have a high inpatient mortality rate, reaching 20% or more in some settings. This makes sepsis and septic shock one of the highest mortality conditions treated in the ED. Additionally, many survivors never fully recover, and instead, long-term morbidities, chronic critical illness, or post-intensive care syndrome develops in them.  , 

Public health and policy efforts seek to reduce the morbidity and mortality associated with sepsis and septic shock through state regulations mandating care, public reporting of hospital performance, the creation of national learning networks, and patient-facing public awareness campaigns.  Despite these efforts, death and incomplete recovery in the following 2 years remains elevated.  ,  Risk-adjusted mortality varies between regions and hospitals, suggesting that nonstandard clinical treatment pathways leave opportunities to improve.  , 

Sepsis care may be most consequential during the earliest phase of treatment. Sepsis in most hospitalized patients in the US (86%) is diagnosed on admission, and up to 80% receive initial care in the ED.  ,  Furthermore, over 75% of ED sepsis patients are treated by emergency medical services (EMS) providers in the out-of-hospital environment.  ,  Thus, both out-of-hospital and inhospital emergency care are key in identifying sepsis and initiating early care for those with life-threatening infection.

Many aspects of emergency sepsis care—recognition, prompt and adequate antibiotic therapy, and circulatory support with fluids and vasopressors for those with septic shock—have evidence-based guiding actions that improve outcomes. Given the inherent difficulty in establishing the early diagnosis of sepsis, any guidance must recognize care elements that influence the timeliness and outcomes of care. Aspects that challenge early care include competing ED diagnoses and care, varying levels of evidence for sepsis recommendations, and treating patients with unnecessary therapy when they ultimately have diagnoses other than sepsis.

Recent policy efforts have intensified the scrutiny placed on clinicians, hospitals, and health systems that deliver sepsis care. In July 2018, the US Centers for Medicare and Medicaid Services (CMS) began public reporting of a national sepsis bundle quality measure, commonly referred to as SEP-1. Early data demonstrated that only half of sepsis patients nationally received the full CMS-recommended bundle for emergency and hospital care.  ,  This finding is unsurprising because clinicians often adjust adherence to guideline-based recommendations based on individual patients and local capabilities. The Surviving Sepsis Campaign offers recommendations on comprehensive sepsis care.  These efforts support better care and outcomes, but they have also raised concerns for those in acute care settings, such as EDs, because they initially applied to undifferentiated patients before the diagnosis of sepsis could be confirmed. 

To address controversies and opportunities for improvement in the emergency care of patients with sepsis in acute early care settings, the American College of Emergency Physicians (ACEP) convened a multispecialty task force in 2019. A core group of emergency physicians initially created a list of areas where concerns existed, using their individual experiences and accumulated feedback from the ACEP, and then a group majority agreement identified which topics the panel would address. We sought to identify key elements of early sepsis care, offer insight to aid future efforts, and suggest practical consensus-based approaches to certain parts of ED sepsis management. The group did not intend to create a new or comprehensive set of ED sepsis care guidelines.

To ensure the inclusion of diverse opinions and perspectives, the ACEP engaged a broad array of experts to address the topics chosen, with the goal of maximizing the consensus of task force recommendations across many audiences. Task force members reviewed existing guidelines, evidence, and medical professional society recommendations; then, a writing committee crafted sections based on an October 2019 in-person meeting of the task force. The consolidated document was shared over 6 months with the full panel for revision and approval. All of the final areas and recommendations reached super majority (75%) approval, eliminating the need for other consensus mechanisms.

We summarize the task force’s assessment of current knowledge and recommendations in this report. We use a format that addresses common steps in the initial emergency care of adults with suspected sepsis. We focused this work on adult sepsis diagnosis and management given recent collaborative pediatric sepsis care guidelines.  The task force product was not created to define a practice standard; we intended to inform physicians’ judgment at the bedside and to help future guideline development by noting areas of concern.

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